Prevent Discharge Disasters

To address frequent and costly hospital readmissions, hospitals and healthcare systems have developed coordinated action plans. One of the most frequently identified areas of concern lies with developing a detailed discharge process. Some hospitals have used nurse advocates to arrange timely follow-up appointments. Pharmacists have been enlisted to provide medication reconciliation to ensure consistency between what is prescribed in the hospital and what the patient will be taking at home. Post-discharge processes have been improved to include pharmacist callbacks to monitor and ensure appropriate medication use and compliance. There are even programs to maximize the use of health information technology to monitor patients in their homes via telehealth and transmit clinical data to their providers.

Patients prescribed high-risk medications are identified when the medications are initiated.

In addition to improving the discharge process, efforts to target high-risk patient populations upon admission also are underway. These efforts include improved admission processes to identify and stratify high-risk patients for future risk of readmission and provide a multidisciplinary team approach to optimize acute care while the patient is in the hospital. In addition, patients prescribed high-risk medications are identified when the medications are initiated to create a discharge regimen that will ensure adherence, decrease pill-burden, and even assist with the financial impact of post-discharge drugs.

While government agencies focus on the high rates of hospital readmission and the associated exorbitant healthcare costs, providers are more appropriately troubled about the large gap in the transition of medical care from the hospital to the home, leading to serious patient harm and, often, deadly outcomes. Healthcare providers, including physicians, pharmacists, nurses, and others, constantly work to eliminate this gap to ensure the safety of their patients.

The Successful Discharge Strategy

A successful hospital discharge plan requires the coordinated efforts of the physician, nurse, pharmacist, patient, caregivers, and an assortment of various community services. A lack of coordination of this complex and integrated process is often the cause of serious post-discharge events and preventable, risky readmissions.

The typical discharge process can be fraught with pitfalls that patients need to anticipate and avoid.(1) These pitfalls can happen when patients are being transferred from the hospital to another facility (e.g., long-term care, rehabilitation, or hospice) or going home. These pitfalls can include(1):

1. Not having a plan of care that details specific medical care needs, including equipment required, changes in diet, medication changes, as well as an assessment of the caregiver’s ability to provide the necessary care;

2. Lack of primary care provider follow-up within one week to assess overall recovery, adjust medications, respond to side effects and adverse reactions, and answer questions about the patient’s care needs;

3. Lack of medication reconciliation between the pre-hospital and post-discharge medications leading to therapeutic duplications and other adverse drug events;

4. Lack of communication with the caregiver, leading to confusion especially with changing wound dressings, administering injectable medications, or transferring the patient from wheelchair to bed; and

5. Lack of support from family and other outside sources, which may lead to improper management of pain, anticoagulant therapy, physical therapy, and so on. Caregivers often need to seek support from the physician or their staff to find solutions to specific issues that arise following discharge.

In isolation, any one of these serious situations could lead to confusion and errors, but if combined, they often leave patients and their caregivers frightened, confused, and back in the emergency department. A complete, coordinated, and standardized approach to the discharge process that bridges the gap from the patient’s day of discharge to their first visit with their primary care provider is necessary to prevent this needless confusion and concern.

Project RED

According to a study published in the Annals of Internal Medicine, patients who had a thorough understanding of their discharge instructions, including proper medication management and when to make follow-up appointments, had a 30% lower chance of being readmitted or visiting the emergency department within 30 days of discharge.(2)

To address the specific challenges of the discharge process, The Re-Engineered Hospital Discharge program (Project RED) was developed for the Agency for Healthcare Research and Quality by Brian Jack, MD, associate professor of family medicine at Boston University, and Timothy Bickmore, PhD, assistant professor in the College of Computer and Information Science at Northeastern University.

Project RED has been shown to decrease hospital readmissions by using a nurse discharge advocate who follows a set of mutually reinforcing components leading to a safe and successful hospital discharge.(3) These components include:

1. Educating patients about their diagnosis throughout the hospital stay;

2. Making appointments for follow-up and post-discharge testing, with input from patient about date and time;

3. Discussing with the patient about any tests not completed in the hospital;

4. Organizing post-discharge services;

5. Confirming the medication plan;

6. Reconciling the discharge plan with national guidelines and critical pathways;

7. Reviewing with the patient the appropriate steps to take in the event a problem arises;

8. Expediting transmission of the discharge summary to clinicians accepting care of the patient;

9. Assessing the patient’s understanding of the plan;

10. Providing the patient with a written discharge plan; and

11. Calling the patient two to three days after discharge to reinforce the discharge plan and help with problem-solving.

In addition to the nurse discharge advocate, Project RED includes a patient-specific After Hospital Care Plan that clearly provides the information patients need to prepare them for the days between discharge and the first visit with their primary care doctor and a medication review phone call from a clinical pharmacist several days after discharge.

Patients and their caregivers should be made aware of the pitfalls they may encounter once they get home.

Project RED has been shown to decrease hospital readmissions by 30% within 30 days of discharge. This equates to reducing one readmission or emergency department visit for every 7.3 patients receiving the intervention. Further, the difference between study groups in total cost was $149,995, or an average of $412 per person who received the intervention. This represents a 33.9% lower observed cost for the intervention group. With more than 38 million hospital discharges in the United States each year, this intervention can drastically reduce cost and greatly improve the overall quality of patient care.(3)

In addition to providing a successful discharge plan, patients and their caregivers should be made aware of the pitfalls they may encounter once they get home. Actively involving the patient and caregiver in discharge discussions will help ensure that medications are taken as prescribed, dressings are changed correctly, and any problems will be addressed appropriately if and when they arise.

Simple Patient Discharge Instructions

• Patients should not leave the hospital without an updated, written list of medications from the physician, nurse, or pharmacist. This list should include all of the medications the patients will be taking when they get home.

• Patients should know which of their old medications they will continue to take when they get home and which ones they should dispose of.

• Pharmacists should be available to provide discharge counseling on all medications the patient will be taking at home. Patients need to be sure that they understand these instructions and should ask questions to get clarification if they do not. Using the teach-back method will help providers ensure patients understand the information provided.

• Upon review of the medication list with the physician, nurse, or pharmacist, patients should be sure they understand what the medications are for, how to take them, and any possible side effects. If patients are not able to do this, have their caregiver review the list of medications with the healthcare provider on their behalf.

• If the patient is not able to comprehend this information, ask the caregiver or advocate to be there when the patient is discharged. They can help by asking questions that may not occur to the patient. The caregiver should bring a pad of paper and a pen to write down all of the important discharge information.

• Patients should know if they should avoid combining any prescription medications with any over-the-counter drugs, vitamins, dietary supplements, or herbal products. Many of these products can cause serious reactions with prescription medications, so patients should ask the pharmacist before taking any nonprescription agents.

• Many drugs, including sedatives and narcotics, interact with alcohol and medical marijuana and should not be taken together. Patients need to know if there are any foods or drinks, including alcoholic beverages, that should be avoided while taking these medications.

• Patients need to know what side effects to expect. They should also know what to do if they experience a side effect, allergic reaction, or other adverse event (including missing doses or doubling up).

• Patients should get their prescriptions filled as soon as possible after leaving the hospital. Serious errors will be prevented by starting new medications according to the schedule provided during the discharge process.

Coordinated Discharge Care

• Begin with the end in mind. Upon admission, identify a healthcare professional to manage post-discharge care.(4)

• Screen and stratify patients upon admission for readmission risk, including disease states and high-risk medications.(5)

• Encourage multidisciplinary daily rounds where all relevant clinicians address both acute care and a discharge regimen.(5)

• Provide clear, detailed discharge plans with considerations for health literacy and primary language spoken.(5)

• Engage patients and families in discharge planning and instructions.(5)

• Provide discharge instructions that meet the patient and caregiver’s needs.(5)

• Identify follow-up providers who can meet unique needs of the patient.(5)

• Arrange to have nurse discharge advocates coordinate timely follow-up appointments to primary care providers with the patient’s convenience in mind.(2)

• Arrange to have nurse discharge advocates arrange timely access to community care services.(4)

• Ensure that medication reconciliation is completed and that all pre-admission medications are compared to post-discharge medications.

• Provide follow-up phone calls from a clinical pharmacist within several days post-discharge to ensure compliance with therapy and to address any medication issues.(2)

• Provide discharge services on weekends, nights, and holidays.(4)

• Identify patients at high risk for readmission and connect them to additional discharge support.(4)

Bottom Line

Leveraging multidisciplinary care and pharmacy services will help patients avoid post-discharge adverse events and dangerous and costly hospital readmissions. Before patients leave the hospital, be certain that they have the information they need, including written instructions that they can refer to after they get home. Have patients speak with the nurse, doctor, or pharmacist about their medications and follow-up care. Be sure patients understand these instructions and follow them closely to prevent a rapid return to their hospital bed.

References

1. Irving C. Five common pitfalls of the hospital discharge process. Family Caregiver Alliance. http://blog.caregiver.org/?p=2040.

2. Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150:178–187.

3. Jack B, Bickmore T. The re-engineered hospital discharge program to decrease rehospitalization. CareManagement. 2010 Dec/2011 Jan: 12-14.

4. National Priorities Partnership/NEHI. Preventing Hospital Readmission: A $25 Billion Opportunity. Cambridge, MA: NEHI, 2010.

5. The Joint Commission. Advancing Effective Communication, Cultural Competence, and Patient and Family Centered Care: A Roadmap for Hospitals. Oakbrook Terrace, IL: The Joint Commission, 2010.

Excerpted from Advancing Excellence in Healthcare Quality: 40 Strategies for Improving Patient Outcomes and Providing Safe, High-Quality Healthcare , by Mary Sue McAslan Pharm.D (American Association for Physician Leadership®, 2014).